198602069-1-3-2024-11-AS-UCOL-D2XVYX-20240301155153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 01/03/2024
Date Signed: 01/03/2024 04:35:28 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231229093425

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	PEGGY CLARK		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 121	DATE:	01/03/2024
		UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Peggy Clark, Administrator		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Licensee did not provide adequate notice of fee increase to resident.

INVESTIGATION FINDINGS:

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On 01/03/24 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Peggy Clark (S1) and the purpose of the visit was explained.

The investigation consisted of the following:
On 01/03/24 LPA requested and reviewed facility documents and toured the facility. LPA interviewed eleven (11) out of one-hundred twenty-one (121) residents, one (1) witness, and three (3) out of seventy (70) staff. LPA reviewed SSI payments notification update, dated 10/10/23, and notification informing the new rental rate, dated 12/01/23.

The investigation revealed the following:
Regarding the allegation: "Licensee did not provide adequate notice of fee increase to resident.".
Report continues, see LIC9099-C.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231229093425

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE	FACILITY NUMBER: 198602069
	VISIT DATE: 01/03/2024

NARRATIVE

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It has been alleged that staff have not provided an amount related to the increase of rent, resulting in further confusion of residents' ability to pay rent on the due date which is 01/03/24. LPA interviewed three staff (S1-S3). All three staff have denied the allegation. LPA interviewed 11 residents (R1-R11). Seven (7) out of eleven (11) residents have agreed with the allegation, while four (4) out of eleven (11) residents were not familiar with the increased rate.

Record reviews revealed that Resident Seven (R7) received a notice of rate increase, without listing the amount, on 10/10/23. Furthermore, Staff Two, Veronica Gomez (S2) showed the same paperwork and informed LPA that it was sent to all Social Security Income / Assisted Living Waiver residents. Resident Three (R3) received a notice of rate increase, listing the increased rate amount, on 01/02/24 and had paid the bill by check on 01/02/24.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. Under Health and Safety Code, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

An exit interview was conducted with Peggy Clark, S1, and a copy of appeal rights and this report were provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20231229093425

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE	FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 01/04/2024 Section Cited HSC 1569.655(a)	1 2 3 4 5 6 7	Health and Safety Code (HSC) 1569.655(a) If a licensee..the licensee shall provide no less than 60 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase,..reason..the increase,..general description..additional costs, except for...a	1 2 3 4 5 6 7	Licensee will create a plan that will inform all residents who had not been notified of the new monthly rate change that has taken place on 01/01/2024. Licensee will also create a plan for all future rate amount changes to be presented to residents or the residents'
	8 9 10 11 12 13 14	change in the level of care of the resident. This subdivision...fee-for-service arrangement with residents. This is not met as evidenced by: Based on interviews with residents and through record reviews, the licensee failed to provide the amount of the increase in a timely manner.	8 9 10 11 12 13 14	representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. Updated plan will be sent to LPA at Mario.Leon@DSS.CA.GOV
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC9099 (FAS) - (06/04)

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